A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Activity intolerance.

Fluid volume excess.

Ineffective airway clearance.

Altered nutrition; less than body requirements.

Answer and Explanation

The Correct Answer is C

Choice A reason: Activity intolerance is important but not the highest priority immediately after surgery.

Choice B reason: Fluid volume excess can be a concern but is not as critical as ensuring effective airway clearance.

Choice C reason: Ineffective airway clearance is the highest priority as it directly impacts the client’s ability to breathe and maintain adequate oxygenation, which is crucial for postoperative recovery.

Choice D reason: Altered nutrition is also important but is not the immediate priority compared to airway clearance.

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Correct Answer is D

Explanation

Choice A reason: Preparing the client for a CT scan is important for diagnostic purposes but is not the immediate priority in managing severe pain.

Choice B reason: Straining the urine for stones is important for confirming the presence of renal calculi but should be done after managing the acute pain.

Choice C reason: Obtaining a urine specimen for analysis is useful for diagnosing infection or other abnormalities but is secondary to pain management.

Choice D reason: Administering a prescribed opioid analgesic is the first priority to relieve the client's severe pain and provide comfort.

A. Call for an assistant. B. Close the room door. C. Finish the procedure. D. Respond to the code.

Correct Answer is A

Explanation

Choice A reason: Calling for an assistant allows the nurse to ensure the client receiving tracheostomy care is safe and monitored while responding to the code blue, which is a priority emergency situation.

Choice B reason: Closing the room door does not address the need for assistance with the ongoing procedure and the emergency.

Choice C reason: Finishing the procedure may delay the nurse's response to the code blue, which requires immediate attention.

Choice D reason: Responding to the code without ensuring the current client is safe can lead to potential complications during tracheostomy care.

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A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Correct Answer is A

Explanation

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